Report Request Form



Date: DATE \@ "dddd, MMMM dd, yyyy" Friday, October 07, 2016Requester Contact Information*:Name: Department: Email (UPHS or PSOM):Phone:Request Approved By: Registry Name*: Request Type*:? Modification/Enhancement to Existing Registry? New Epic-Released Registry? New Custom RegistryRegistry Type (for new registry): ? Patient-based (one record for each patient)? Contact-based (one record for each contact/encounter)Clinical Relevancy* impact on patient care. example: patient safety, patient outreach, closing care gap, reduce readmission) Financial Impact* (example, reduce cost, avoid redundant care)Will be used to External Reporting*? Yes? NoFunded and Supported by Ongoing Grant*? Yes? NoPurpose*: Please provide specific details on the objectives of this registry. This will better help us meet your specific needs. Expected Date in Production: Define Required Inclusion Criteria*This will determine WHO is in the registry, and not necessarily the metrics that are calculated by the registry. Some potential inclusion criteria are listed below.CriteriaDescriptionGrouper IDCode (ICD-10, CPT, etc.)Exclusions, additional filters, etc.Problem List DiagnosisEncounter DiagnosisPlease specify if there is a minimum number of encounters that should have this diagnosisProceduresOrdersMedicationsAgeGenderRaceLab ResultNumber of EncountersPlease specify if there are certain encounter types that should be included/excluded (i.e. Office Visit)Number of AdmissionsNumber of ED VisitsDepartment/LocationDate(s)Include in the specific range and date types (i.e. admit, order, result)OtherOtherOtherOtherOtherOtherOtherOtherOtherOtherDefine Required Registry Metrics*This will determine what types of data the registry should calculate/display. Examples include Age, Race, PCP, last office visit, last HbA1c result, last LDL result, last eye exam date, etc.MetricDescriptionGrouper IDCode (ICD-10, CPT, etc.)Exclusions, additional filters, etc. ................
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